Functional results and quality of life after treatment of pelvic sarcomas involving the acetabulum

Less is better than more with resection of periacetabular tumors - A retrospective 16 years study and literature review

Introduction

Wide resections of periacetabular tumors create a sizeable bony defect that inevitably results in severe loss of function. Reconstruction of such defects usually requires using large metal implants, a feature associated with considerable surgery extension and complications. The aim of this study is to report resection with no reconstruction of the bony defect. In this retrospective study, we reviewed a consecutive series of 16 patients diagnosed with malignant periacetabular tumors and underwent en-bloc resection without reconstructing their remaining bone defect.

Methods

Records were reviewed of 16 consecutive patients diagnosed with malignant periacetabular tumors and underwent en-bloc resection without reconstructing their remaining bony defect. Measurements included: the duration of surgery, blood loss, hemoglobin levels and the need for blood transfusions, data on other hospitalization characteristics, and intraoperative and postoperative complications.

Results

Sixteen patients with malignant periacetabular bone tumors and extensive bone destruction underwent wide periacetabular tumor resection with a mean follow-up of 75 months and a mean age of 53 years. The average HOOS score was 46 (range: 20 to 76), and the mean MSTS score was 13% (range: 0 to 15). The mean operative time was 4.1 h, and the mean blood loss was 1200 ml. At their most recent follow-up, patients had a mean shortening of their operated extremity of 4.8 cm, and all could ambulate with assisting devices.

Conclusion

Wide resection of periacetabular tumors without reconstruction provides acceptable levels of function and was associated with shorter surgical time, less blood loss and fewer postoperative complications compared to resection with reconstruction. Therefore, this approach may be considered a viable surgical option in patients with an extensive malignant periacetabular.

Level III

Retrospective study.

A novel limb-salvage reconstruction strategy with a custom hemipelvic endoprosthesis and preserved femoral head following the resection of periacetabular tumors: A preliminary study

The treatment of periacetabular malignancy frequently challenges surgeons. To simplify the surgical procedure, we performed a novel reconstruction strategy preserving the femoral head for patients with periacetabular malignancies. We retrospectively reviewed 14 patients who underwent total en bloc resection of a periacetabular tumor and reconstruction of the hip joint with an individualized hemipelvic endoprosthesis and remaining femoral head from July 2015 to January 2019 at our center. Regions of pelvic resection: region II-4 (28.6%), region I + II-5 (35.7%), region II + III-2 (14.3%) and region I + II + III-3 (21.4%). The oncological outcomes were that 13 patients survived without disease and one patient survived with lung metastasis. None of the patients experienced local recurrence (range: 20-62 months; mean: 32 months). The incidence of postoperative complications was 35.7%, including delayed wound healing and deep venous thrombosis. No prosthesis-related complications occurred until the last follow-up in this study (range: 20-62 months; mean: 32 months). The mean Musculoskeletal Tumor Society functional outcome score was 23.2. The mean Toronto Extremity Salvage Score of the patients was 75.7 points, with a mean limb discrepancy of 1.51 cm (range: 0.5-3.2 cm). Reconstruction with preservation of the femoral head showed acceptable early functional and oncological outcomes, and it had an acceptable complication rate.

Extra-articular resection of the hip joint for pelvic sarcomas: Are there any oncological and functional risks compared with intra-articular resection?

BACKGROUND

While extra-articular resection (EAR) of the knee and shoulder joint is associated with poorer clinical outcomes, the oncological and functional risks of EAR of the hip joint are unknown. We aimed to compare these risks between EAR of the hip joint and intra-articular resection (IAR).

METHODS

We conducted a comparative study of 75 patients who underwent en-bloc tumour resection and limb-salvage reconstruction for bone sarcomas of the peri-acetabulum between 1996 and 2016. We divided patients into two groups for analyses; EAR (n = 21) and IAR (n = 54).

RESULTS

There was no statistical difference in oncological outcomes; the 5-year cumulative incidence of disease-specific death was 34% and 35% in the EAR and IAR groups, respectively (p = 0.943), and the 5-year cumulative incidence of LR was 26% and 34%, respectively (p = 0.482). The most common complications were dislocation (28%) and deep infection (28%); there was equally no difference between the groups. The mean Musculoskeletal Tumour Society score was 66% and 65% in the EAR and IAR groups, respectively (p = 0.795), and were significantly lower in patients with deep infection (52% vs. 69%; p = 0.013). In a sub-analysis on the outcomes in patients who underwent PI-uninvolved PII-resection for chondrosarcoma, no major differences in oncologic and functional outcomes were confirmed.

CONCLUSION

Patients undergoing EAR and limb-salvage reconstructions of the hip joint have undistinguishable oncological, clinical and functional outcomes compared to those undergoing IAR and reconstructions. If preoperative imaging suggests articular tumour involvement, there appears to be no detrimental effect of undertaking EAR to optimise local control.

Periacetabular reconstruction following limb-salvage surgery for pelvic sarcomas

Limb-salvage surgery for pelvic sarcomas remains one of the most challenging surgical procedures for musculoskeletal oncologists. In the past several decades, various surgical techniques have been developed for periacetabular reconstruction following pelvic tumor resection. These methods include endoprosthetic reconstruction, allograft or autograft reconstruction, arthrodesis, and hip transposition. Each of these procedures has its own advantages and disadvantages, and there is no consensus or gold standard for periacetabular reconstruction. Consequently, this review provides an overview of the clinical outcomes for each of these reconstructive options following pelvic tumor resections. Overall, high complication rates are associated with the use of massive implants/grafts, and deep infection is generally the most common cause of reconstruction failure. Functional outcomes decline with the occurrence of severe complications. Further efforts to avoid complications using innovative techniques, such as antibiotic-laden devices, computer navigation, custom cutting jigs, and reduced use of implants/grafts, are crucial to improve outcomes, especially in patients at a high risk of complications.

Impact of Surgical Resection and Reasons for Poor Prognosis of Pelvic Osteosarcoma Based on the Bone Tumor Registry in Japan

Simple Summary

Pelvic osteosarcoma has a poor prognosis compared to osteosarcomas in other locations, and the reasons for this remains unknown. Surgical resection of pelvic osteosarcoma is technically demanding and often results in dysfunction and complications. In this study, we investigated the reasons underlying the poor prognosis of pelvic osteosarcoma by comparing it to femoral osteosarcoma using data from the Bone Tumor Registry in Japan. We used propensity score analysis to determine whether surgical resection of pelvic osteosarcoma improved its prognosis. We demonstrated that pelvic osteosarcoma had a poor prognosis because it occurred more often in the elderly, often had a larger tumor size, and had metastasis at presentation more often in comparison to femoral osteosarcoma. These three factors were also associated with the non-surgical treatment of pelvic osteosarcoma, which also led to a poor outcome. The overall survival rate was only comparable in pelvic osteosarcoma and femoral osteosarcoma in cases treated with surgical resection. Propensity score analysis revealed that surgical treatment improved the prognosis of pelvic osteosarcoma. As such, we propose that surgical resection should be considered based on tumor stage and patient age in order to improve the prognosis of pelvic osteosarcoma.

Abstract

Pelvic osteosarcoma has a poor prognosis compared to osteosarcomas in other locations, and the reasons for this remain unknown. Surgical resection of pelvic osteosarcoma is technically demanding and often results in dysfunction and complications. In this study, we investigated the reasons underlying the poor prognosis of pelvic osteosarcoma by comparing it to femoral osteosarcoma using data from the Bone Tumor Registry in Japan. We used propensity score analysis to determine whether surgical resection of pelvic osteosarcoma improved its prognosis. We demonstrated that pelvic osteosarcoma had a poor prognosis because it occurred more often in the elderly, often had larger tumor size, and had metastasis at presentation more often in comparison to femoral osteosarcoma. These three factors were also associated with the non-surgical treatment of pelvic osteosarcoma, which also led to a poor outcome. The overall survival rate was only comparable in pelvic osteosarcoma and femoral osteosarcoma in cases treated with surgical resection. Propensity score analysis revealed that surgical treatment improved the prognosis of pelvic osteosarcoma. As such, we propose that surgical resection should be considered based on tumor stage and patient age in order to improve the prognosis of pelvic osteosarcoma.

Pelvic reconstruction using an ice-cream cone prosthesis: correlation between the inserted length of the coned stem and surgical outcome

BACKGROUND

Acetabular reconstruction using an ice-cream cone prosthesis has been a reliable reconstruction option following pelvic tumour resection. However, it remains unknown which factor determines the success of this procedure. We aimed to determine risk factors for complications and functional loss in acetabular reconstruction using an ice-cream cone prosthesis.

PATIENTS AND METHODS

Fifty-four patients with malignant bone tumours who underwent acetabular reconstruction using an ice-cream cone prosthesis between 2004 and 2016 were studied. The bone-stem ratio was calculated as the ratio of the inserted length into the bone per the entire stem length.

RESULTS

A total of 26 (48%) patients had at least one complication and 11 patients (20%) required surgical interventions. The complication rates were 71% and 40% with a bone-stem ratio ≤ 50% and > 50%, respectively (p = 0.026), and the bone-stem ratio significantly stratified the risk of complications (≤ 50%: OR, 4.67 versus > 50%; p = 0.048). The mean MSTS score at the final follow-up was 60% (range 23-97%): the scores were significantly lower in patients with complications/leg-length discrepancy (52%) than in those without (79%; p = 0.002). The mean score with a bone-stem ratio ≤ 50% was significantly lower than the score with a ratio > 50%, especially in patients who underwent non-navigated reconstructions (33% versus 64%; p = 0.001).

CONCLUSION

The inserted length of the coned stem into residual bone was predictive of complications and functional outcome. Surgical indication for this procedure should be considered with the size of the remaining ilium to stabilise the prosthesis with a coned stem longer than half length.

Unraveling the Heterogeneity of Sarcoma Survivors' Health-Related Quality of Life Regarding Primary Sarcoma Location: Results from the SURVSARC Study

Simple Summary

Sarcomas are a rare group of heterogenous tumors that can develop anywhere in the body. Currently, studies on health-related quality of life (HRQoL) focus on sarcomas of the arm and leg or have too small sample sizes to examine the heterogeneity between different sarcoma locations, leading to limited insight into HRQoL of survivors with specific sarcoma locations. The aim of this study was to assess differences in HRQoL and examine treatment-specific HRQoL issues per sarcoma location. We found, in a population of 1099 sarcoma survivors, different patterns of HRQoL according to primary sarcoma location and a high number of additional, unique treatment-specific HRQoL issues per location, which were not captured with the general HRQoL questionnaire used in cancer patients. This indicates that the currently used HRQoL measures are too generic to capture all sarcoma-related issues, emphasizing the necessity for a comprehensive sarcoma-specific HRQoL measurement strategy.

Abstract

Sarcoma patients experience physical and psychological symptoms, depending on age of onset, subtype, treatment, stage, and location of the sarcoma, which can adversely affect patients’ health-related quality of life (HRQoL). This study aimed to unravel the heterogeneity of sarcoma survivors’ HRQoL regarding primary sarcoma location. A cross-sectional study was conducted among Dutch sarcoma survivors (N = 1099) aged ≥18, diagnosed 2–10 years ago. Primary sarcoma locations were head and neck, chest, abdominal including retroperitoneal, pelvis including urogenital organs, axial skeleton, extremities (upper and lower), breast, skin and other locations. The European Organization for Research and Treatment of Cancer—Quality of Life Questionnaire (EORTC QLQ)-C30 was used to measure HRQoL accompanied by treatment-specific HRQoL questions. Sociodemographic and clinical characteristics were collected from the Netherlands Cancer Registry. Axial skeleton sarcomas had the lowest functioning levels and highest symptoms compared to other locations. Skin sarcomas had the highest functioning levels and lowest symptoms on most scales. Bone sarcomas scored worse on several HRQoL domains compared to soft tissue sarcomas. High prevalence of treatment-specific HRQoL issues were found per location. In conclusion, sarcomas can present everywhere, which is reflected by different HRQoL outcomes according to primary sarcoma location. The currently used HRQoL measure lacks treatment-specific questions and is too generic to capture all sarcoma-related issues, emphasizing the necessity for a comprehensive sarcoma-specific HRQoL measurement strategy.

Implementation of the three-dimensional printing technology in treatment of bone tumours: a case series

PURPOSE

With the ability to overcome specific anatomical and pathological challenges, 3D printing technology is setting itself as an important tool in patient-specific orthopaedics, delivering anatomical models, patient-specific instruments, and custom-made implants. One of the most demanding procedures in limb salvage surgery is the reconstruction of bony defects after tumour resection. Even though still limited in clinical practice, early results of the use of 3D technology are gradually revealing its potentially huge impact in bone tumour surgery. Here, we present a case series illustrating our experience with the use of 3D printing technology in the reconstruction of bone defects after tumour resection, and its impact on cosmesis and quality of life.

METHODS

We performed a retrospective analysis of 11 patients in whom a custom-made 3D-printed prosthesis was used to reconstruct a bone defect after resection for a bone tumour. Ten out of 11 patients were children (aged between 5 and 16 years) with osteosarcoma or Ewing sarcoma of the pelvis (2 children) or the arm (8 children), and one patient was a 67-year-old lady with a chondrosarcoma of the pelvis. All underwent wide resections resulting in considerable bone defects necessitating further reconstruction.

RESULTS

Custom-made implants were extremely useful both in reconstruction of bone defects and in terms of cosmesis, recovery facilitation, and quality of life. In this respect, pelvic and humeral reconstructions with 3D-printed custom implants particularly showed a great potential. The mean follow-up was 33 months. Four patients died of disease (36%) and overall the major and minor complication rate was 54% (6 out of 11 patients). Three patients had implant dislocation (27% [3/11 cases]), one had leg-compartment syndrome, and one patient reported limited range of motion. Only two out of 11 patients developed local recurrence.

CONCLUSION

Use of 3D customized implant helped us achieve two major goals in orthopaedic oncology-clear surgical resection and functional recovery with a good quality of life. Large studies with long-term follow-up are needed to reveal the value and future of 3D printing in orthopaedic oncology.

Complication rate, functional outcomes, and risk factors associated with carbon ion radiotherapy for patients with unresectable pelvic bone sarcoma

BACKGROUND

To the authors' knowledge, carbon ion radiotherapy (CIRT) is one of the few curative treatments for unresectable pelvic bone sarcoma. The current study investigated the complications, functional outcomes, and risk factors of CIRT.

METHODS

Of 112 patients who were treated with CIRT for unresectable pelvic bone sarcoma, the authors enrolled 29 patients who were without local disease recurrence or distant metastasis. The mean follow-up was 93 months. Complications, functional outcomes, and quality of life scores were assessed. Risk factors were analyzed, including the dose-volume histogram of the femoral head.

RESULTS

Femoral head necrosis occurred in approximately 37% of patients, pelvic fractures were reported in 48% of patients, and neurological deficits were noted in 52% of patients. Femoral head necrosis was found to be significantly more prevalent among patients with periacetabular tumors (P = .018). The dose-volume histogram of the femoral head indicated tolerable volume percentages of the femoral head to be <33% for 40 grays (relative biological effectiveness) and 16% for 60 grays ( relative biological effectiveness). The mean Musculoskeletal Tumor Society score and Toronto Extremity Salvage Score were 53% and 64%, respectively, and the mean EuroQol 5 dimensions questionnaire index was 0.587. Patients aged >50 years and those with periacetabular tumors were found to have significantly lower Toronto Extremity Salvage Scores.

CONCLUSIONS

Femoral head necrosis, pelvic fracture, and nerve damage are common complications with the use of CIRT for pelvic bone sarcoma. To prevent femoral head necrosis, the radiation dose to the femoral head should be kept below the estimated tolerance curve presented in the current study. The functional outcome is nearly equivalent to that of surgery. CIRT may be a promising alternative to surgery for patients with unresectable pelvic bone sarcoma.

Complications following Iliac Wing Fibrosarcoma

The aim of this case report is to underline surgical strategies for complications in a case of a young man with fibrosarcoma of the bone treated with pelvic resection followed by reconstruction with massive bone allograft. A type I pelvic resection was performed as a radical resection of tumor followed by a biological reconstruction of iliac wing using frozen allograft. The iliac allograft was fixed in place using 4 screws. The immediate postoperative period was complicated with local sepsis of reconstructed site treated with pediculate omentoplasty. After 1 year from surgery, the X-ray exam showed an integrated allograft. After 20 years from the first surgery, the patient presented with the left hip pain of 3-month duration with mechanical pattern. The X-ray and CT exam showed the left hip arthritis and no signs of recurrence. A total hip arthroplasty with dual mobility cup and uncemented stem was performed. Despite the immediate postoperative local infection, the allograft was left in place and integrated after all. Omentoplasty could be a very useful technique in eradicating local infection, due to the immunogenic properties of the omentum. The allograft is still strong enough to give support for a hip arthroplasty at 20 years after implantation.

Temporary External Fixation Can Stabilize Hip Transposition Arthroplasty After Resection of Malignant Periacetabular Bone Tumors

BACKGROUND

The choice of reconstructive procedure to restore limb function is challenging after internal hemipelvectomy. Hip transposition arthroplasty, also known as resection arthroplasty, removes a malignant or aggressive tumor of the pelvis and acetabulum after which the remaining femoral head is moved proximally to the lateral surface side of the sacrum or the underside of the resected ilium after internal hemipelvectomy. It may provide reasonable functional results and have some advantages such as lowering the risk of an infected implant compared with other reconstructions because no foreign implants are used. Hip transposition is generally managed with prolonged bed rest or immobilization postoperatively to stabilize the soft tissue surrounding the remaining femur. Because enabling patients to be mobile while the soft tissues heal might be advantageous, we reviewed our experience with an external fixation for this procedure.

QUESTIONS/PURPOSES

(1) Does temporary external fixation facilitate postoperative physiotherapy in patients who undergo hip transposition arthroplasty? (2) What functional Musculoskeletal Tumor Society (MSTS) scores were achieved at short term in a small series of patients treated with hip transposition and temporary external fixation? (3) What were the complications of using external fixation in a small series of patients who received it for malignant tumors?

METHODS

Between 2008 and 2012, we treated seven patients (three men and four women; median age, 37 years; age range, 18-53 years) with acetabular resection for malignant bone tumors; all were managed with a hip transposition, initially stabilized using external fixation. No other types of procedures were used for this indication in this period. Minimum followup in this retrospective study was 45 months, except for one patient who died at 18 months (range of followup duration, 18-90 months; median followup, 57 months), and no patients were lost to followup. The pins for external fixation were inserted into the affected side of the femur and the healthy contralateral ilium. External fixation was removed 6 weeks postoperatively and weightbearing was started at that time. Preoperative chemotherapy was administrated in four patients, but postoperative chemotherapy was delayed since it was given after external fixation removal in three patients. The postoperative rehabilitation course and functional results were assessed by chart review, functional results were determined using MSTS scores, tallied by physiotherapists who were not part of the surgical team, and complications were ascertained through chart review. Major complications were defined as complications that were treated with additional operations, such as deep infection, or ones that could cause severe postoperative dysfunction, such as nerve injury.

RESULTS

With temporary external fixation, standing next to a bed was achieved in median 7 days (range, 6-9 days) postoperatively, transferring to a wheel chair in median 8 days (range, 6-28 days), and gait training using parallel bars in median 15 days (range, 7-48 days). At most recent followup, three patients could walk without a crutch or cane, three could walk with a cane, and one could walk with a crutch. The median MSTS score at most recent followup (median, 57 months) was 63%. Two patients had complications that resulted in reoperations; one had a wound dehiscence, and one had an abdominal herniation that gradually developed, and which was reconstructed using polypropylene mesh 2 years after pelvic resection. Two patients had nerve palsies that recovered by the end of the first year. All patients had pin tract infections that resolved with nonsurgical approaches.

CONCLUSIONS

Hip transposition with temporary external fixation can stabilize the bone soft tissue after pelvic resection. Although we did not have a comparison group of patients, we believe that external fixation facilitates early postoperative physiotherapy and rehabilitation and provides good functional results without major surgical complications. Because it delays the resumption of chemotherapy, more patients with longer followup are needed to determine whether this will be associated with poorer oncologic results.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

A Critical Review of the Impact of Sarcoma on Psychosocial Wellbeing

Background

Previous reviews of outcomes in specific sarcoma populations suggest patients have poor quality of life. In most of these reviews, there is a predominant focus on physical function rather than psychosocial outcome. The aim of this review was to describe the psychosocial impact of diagnosis and treatment on patients with all types of sarcoma.

Methods

Searches were conducted through six electronic databases for publications of any study design using a validated patient-reported outcome measure reporting the psychosocial impact in this population.

Results

Eighty-two studies fulfilled the inclusion criteria. Most (65%) were assessed of being of reasonable quality. The most common aspect of psychosocial wellbeing measured was quality of life (80%). Due to the heterogeneity of methods, outcomes, and populations, it was not possible to make definitive conclusions. It seems there is an improvement in the physical aspects of quality of life over time but not in psychosocial function or mental health. There was no change in mental health scores, but patients reported an improvement in adjusting to normal life. There are no differences according to the type of surgery patients receive, and psychosocial outcomes tend to be poorer than the general population. There is no consistency in identifying the factors that predict/influence psychosocial wellbeing.

Conclusion

The published literature does not provide a clear understanding of the impact of sarcoma diagnosis and treatment on psychosocial wellbeing. Instead, the review demonstrates a need for well-designed studies in this area and a more consistent approach to the measurement of patient-reported outcomes, which include psychosocial domains. Recommendations for future research have been proposed.

Upshifting the Ipsilateral Proximal Femur May Provide Satisfactory Reconstruction of Periacetabular Pelvic Bone Defects After Tumor Resection

BACKGROUND

Pelvic ring reconstruction after resection of pelvic malignancies or aggressive benign tumors remains challenging, especially when the tumor invades periacetabular bone, resulting in a Type II resection as classified by Enneking and Dunham (removal of part or all of the acetabulum). Although numerous treatment approaches are in use, none is clearly superior to the others. An alternative involving use of the ipsilateral proximal femur as an autograft has not been well characterized, so we present our preliminary experience with this approach.

QUESTIONS/PURPOSES

(1) What were the oncologic outcomes after using an ipsilateral proximal femur autograft for reconstruction after Type II pelvic resection in a small series of patients who underwent this reconstructive approach? (2) What were the Musculoskeletal Tumor Society (MSTS) scores after this reconstruction? (3) What complications were observed?

METHODS

Between October 2006 and May 2016, we treated 67 patients with Type II malignant or aggressive benign tumors of the ilium. Of those, we used an ipsilateral proximal femur and a prosthesis as a reconstruction method for 11 patients with pelvic tumors. In general, we performed this approach in young or middle-aged patients with primary malignant or aggressive benign tumors involving pelvic area II and in whom the tumor did not invade the hip. The method used for resection of pelvic tumors included osteotomy of the femoral shaft, harvesting the proximal femur as a graft. The length of the femoral graft was determined by the extent of the pelvic defect. The proper placement was selected after a comparison of the proximal femur and the pelvic defect. A curved reconstruction plate and cancellous bone screws were used for pelvic fixation. The operative duration and total blood loss were recorded. Of the 11 patients who underwent this approach, all but one had at least 2 years of followup unless death occurred earlier, and all but one have been seen within the last year for evaluation. Functional outcomes were assessed using the MSTS scoring system. Local recurrence, metastases, and deaths were recorded as were complications including infection, bone nonunion, mechanical failure and sciatic nerve palsy.

RESULTS

The followup was a mean of 37 months (range, 13-96 months). One patient was lost to followup. Three patients died of disease owing to local recurrence or lung metastasis. The other seven patients lived without evidence of tumor. The main complications included mechanical failure in two patients, nonunion in one patient, infection in two patients, and sciatic nerve palsy in one patient. The median MSTS function score was 70% (21 of 30 points; range, 11-25 points).

CONCLUSIONS

Our preliminary results show that this technique of using the ipsilateral proximal femur may be an alternative method for reconstruction of pelvic bone defects after tumor resection. Even with this short followup, complications were common, but short-term function appears to be comparable to studies of other options. Longer term followup with more patients is necessary to confirm our results.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Early Clinical Outcomes of a New Posteriorly Stabilized Total Knee Arthroplasty Prosthesis: Comparisons with Two Established Prostheses

Purpose

We sought to determine whether early clinical performance of new posterior stabilized (PS) knee system, the Vega-PS (Aesculap), is better than that of two established total knee arthroplasty (TKA) prostheses, the E.motion-PS (Aesculap) and the Genesis II (Smith & Nephew) in terms of functional outcomes, patient satisfaction, and incidence of adverse events.

Materials and Methods

We compared the clinical outcomes of 206 consecutive TKAs using Vega-PS with those of 205 TKAs using E.motion-PS and 216 TKAs using Genesis II at 2 years of follow-up.

Results

Overall, the knees with the Vega-PS had better functional outcome scores than the knees with the E.motion-PS, but had similar outcome scores to the knees with the Genesis II, as evident from the American Knee Society knee score (94.2 vs. 92.5 vs. 93.2), Western Ontario McMaster Universities Osteoarthritis (WOMAC) stiffness index (1.8 vs. 2.3 vs. 2.0), WOMAC function index (11.8 vs. 16.8 vs. 18.5), Short Form 36 (SF-36) physical component summary score (41.9 vs. 39.3 vs. 41.6), and SF-36 mental component summary score (50.0 vs. 45.8 vs. 46.9). Patient satisfaction was higher in the Vega-PS and Genesis II groups than the E.motion-PS group. No notable group differences were found in terms of the incidence of adverse events.

Conclusions

The Vega-PS, a newly developed PS fixed bearing prosthesis, had comparable or superior clinical performance in comparison with the two established fixed or mobile bearing PS prostheses.

Comparison of Pasteurized Autograft-Prosthesis Composite Reconstruction and Resection Hip Arthroplasty for Periacetabular Tumors

Background

Because of the high complication rate of anatomical reconstruction after periacetabular resection, the strategy of resection alone has been revisited. However, in terms of complications and functional outcome, whether resection hip arthroplasty (RHA) shows a superior result to that of pelvic ring reconstruction remains controversial.

Methods

We compared 24 RHAs and 16 pasteurized autograft-prosthesis composite (PPC) reconstructions regarding the complication rates, operative time, blood loss, and functional outcome.

Results

Compared to 16 PPC hips, 24 RHA hips showed lower major and minor complication rates (p < 0.001), shorter surgical time (p < 0.001), and superior Musculoskeletal Tumor Society scores (p < 0.001). Of the 24 RHA hips, bony neo-acetabulum was identified in 7 on computed tomography and partial neo-acetabulum in 9; the remaining 8 had no bony acetabular structure. The average time to bony neo-acetabulum formation was 7 months (range, 4 to 13 months).

Conclusions

RHA for periacetabular tumors can be an excellent alternative to anatomical reconstruction. It offers short surgical time, low complication rates, and functional results comparable to those of other reconstruction methods. However, this procedure is indicated for patients who can accept some limb shortening, and a tumor should be confined to the periacetabular area.

[Extracorporeal irradiation : Reimplantation of bone segments in the treatment of malignant bone tumours]

BACKGROUND

Malignant bone tumors themselves and the wide resection required because of them may cause huge bone defects in the bone segment involved. Autologous bone grafts are a reliable option to cover these defects in many cases but their availability is limited. Besides common alternative reconstruction methods, including the use of allografts and/or prostheses, especially extracoroporeal irradiation (ECI) and reimplantation of the bone segment involved is attracting increasingly more attention nowadays.

DISCUSSION

In the following, we report on indications/contraindications, details of the operative technique, as well as the recommended rehabilitation regime of ECI. Furthermore, we compare our own results with those published in the recent literature. Especially the advantages and disadvantages of this method, the risks and the complications are illustrated and critically discussed.

CONCLUSION

Extracorporeal irradiation of a tumor bearing bone segment is a valuable alternative reconstruction technique following tumor resections of the pelvis, femur and tibia, with encouraging results with respect to local control, complication risks and functional outcome.

Is It Possible and Safe to Perform Acetabular-preserving Resections for Malignant Neoplasms of the Periacetabular Region?

BACKGROUND

Primary malignant tumors located near the acetabulum are usually managed by resection of the tumor with wide margins that include the acetabulum. These resections are deemed P2 resections by the Enneking and Dunham classification. There are various methods to perform the subsequent hip reconstruction. Unfortunately, there is no consensus as to the best management. In general, patients undergoing resection at this level will have substantial levels of pain and disability as measured by the Musculoskeletal Tumor Society (MSTS) scoring system. We believe there is a subset of patients whose tumors in this location can be resected while preserving all or most of the weightbearing acetabulum using navigation and careful surgical planning.

QUESTIONS/PURPOSES

(1) What complications were associated with this resection; (2) what oncological outcomes (histological margins and local recurrence) were achieved; and (3) what is the function achieved by these patients?

METHODS

This was a retrospective study of patients with periacetabular primary malignancy. From 2008 to 2014, we treated 12 patients who had periacetabular primary malignant tumors and in five, we performed resection with the weightbearing portion spared. During this period, our general indications to perform a resection that spared the acetabulum were the tumor with its resection margin not involving the weightbearing portion of the acetabulum. However, we did not perform this procedure in patients who had more cranial lesion involving the weightbearing portion or whose hip stability might be in question after the tumor excision. Three patients were women and the other two were men. Four were chondrosarcomas, whereas the other one was synovial sarcoma. Ages ranged from 46 to 60 years (average, 53 years). Minimum followup was 14 months (median, 37 months; range, 14-88 months); no patients were lost to followup before a 1-year minimum was achieved, and all patients have been seen within the last 9 months.

RESULTS

There were no intraoperative or early postoperative complications. None of the five patients had a positive margin by histological assessment. No local recurrences were detected. The median functional score by MSTS was 28 out of 30 (range, 27-30).

CONCLUSIONS

The roof of the acetabulum is the weightbearing portion of the acetabulum. It also maintains the stability of the hip. With precise preoperative planning of the resection and accurate execution of the procedure, the hip-sparing approach through partial acetabular resection can be performed in selected patients with malignant periacetabular neoplasms. Navigation makes it possible to minimize the amount of bone resection. In this preliminary report of a small number of patients, we had adequate short-term local tumor control. We believe the function is good, but we do not have a comparison group of patients to document improved function.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Pasteurized autograft reconstruction after resection of periacetabular malignant bone tumours

Background

The treatment of periacetabular malignant bone tumours is challenging. Many methods of reconstruction after internal hemipelvectomy have been reported and each method has its own limitations. The aim of this study was to evaluate the oncological and functional outcomes of pasteurized autograft reconstruction after resection of periacetabular malignant bone tumours.

Methods

Ten patients (six male, four female) with periacetabular malignant tumours, who underwent resection and reconstruction with pasteurized autograft, were retrospectively reviewed. The patients’ average age at diagnosis was 40 years (range 13–65 years). There were five patients with chondrosarcoma, three with osteosarcoma, one with Ewing’s sarcoma, and one with solitary metastatic thyroid carcinoma.

Results

At the last follow-up, seven patients were alive (six with no evidence of the primary disease and one with lung metastasis for 5 months). The three other patients died of metastasis of the primary disease with a mean survival time of 12 (range 8–17) months postoperatively. The mean follow-up time for all patients was 45 (range 8–87) months. Local recurrence rate was 10%. The mean time of bone union was 12 (range 6–21) months after the operation. The mean Musculoskeletal Tumor Society score for all living patients at the last follow-up was 70.5% (range 43.3–86.7%).

Conclusions

Reconstruction with pasteurized autograft is a feasible method for treating periacetabular malignant bone tumours, with satisfactory oncological and functional outcomes and a relatively low incidence of complications.

Cross-cultural adaptation and validation of the Chinese version of Toronto Extremity Salvage Score for patients with extremity sarcoma

Objective

As a widely used instrument for patients with extremity sarcoma, the Toronto Extremity Salvage Score (TESS) has never been cross-culturally adapted for Chinese population. The objective of our study was to investigate the comprehensibility, reliability and validity of the Chinese version of TESS for use in patients with extremity sarcoma.

Methods

A consensus version of the Chinese TESS was developed under the review of a committee according to international guidelines. 64 patients were recruited to complete the Chinese TESS, the Musculoskeletal Tumor Society (MSTS) Rating Scale, and the Quality of Life Questionnaire Core 30 (QLQ-C30). Reliability was assessed using the intra-class correlation coefficient (ICC) and Cronbach’s α. Validity was assessed with Pearson’s correlation between the similar domains of the two questionnaires.

Results

The ICCs for the test–retest reliability was 0.932 for the upper extremity questionnaire and 0.893 for lower extremity questionnaire, respectively. The Cronbach’s α was 0.953 for the lower extremity questionnaire and 0.921 for the upper extremity questionnaire, respectively. Convergent validity of the TESS based on Pearson correlation coefficients indicated significantly moderate to high correlations between the TESS and the MSTS as well as the QLQ-C30, with r ranging from 0.535 to 0.782.

Conclusions

The Chinese TESS is a comprehensible, reliable, and valid instrument that can be utilized for future cross-cultural international studies of extremity sarcoma.

Malignant Pelvic Tumors Involving the Sacrum: Surgical Approaches and Procedures Based on a New Classification

OBJECTIVE

To introduce a new classification of Enneking type IV pelvic tumors involving the sacrum and a corresponding system of standardized surgical approaches and procedures for resection of such tumors, and to investigate the feasibility and therapeutic effect of the new system.

METHODS

Data on 59 patients treated between February 2003 and February 2013 by standardized surgical approaches and procedures were retrospectively reviewed. The study subjects comprised 28 male and 31 female patients with a mean age at diagnosis of 36 years (range, 2-72 years). There are four subtypes in the new classification: (i) subtype IVa, neoplasms invading the ipsilateral sacral wing; (ii) subtype IVb, neoplasms invading the ipsilateral sacral foramina; (iii) subtype IVc, neoplasms invading the contralateral sacral foramina; and (iv) subtype IVd, neoplasms invading the whole of the sacrum. Standardized surgical approaches and procedures were devised for en-bloc resection for each subtype with adequate margins.

RESULTS

Adequate margins were achieved in 43/59 patients (72.9%). The mean operation time was 5.0 h and the mean intraoperative blood loss 2157 mL. At the final follow-up, 27/53 patients (50.9%) who had been followed up were alive and in complete remission. The mean Musculoskeletal Tumor Society 93 score was 17.4 (58%) of a possible 30 points. The mean functional score for patients who had undergone a pelvic zone II resection was 15.2, compared with 19.0 for those with an intact pelvic zone II.

CONCLUSIONS

The proposed standardized protocols should help orthopaedic surgeons to achieve adequate margins, manage risk, achieve better oncologic and functional outcomes, and minimize perioperative complications when treating massive pelvic tumors involving the sacrum.

Treatment of metastatic lesions localized in the acetabulum

BACKGROUND

Metastatic lesions localized in the periacetabular area cause troublesome pain and reduced mobility of the patients. Radiotherapy effectively decreases pain, yet it does not restore the ability to load the joint. Surgical treatment involving resection of metastatic lesions and joint reconstruction using bone grafts is burdened with a high rate of complications. Modular tumor prostheses are being increasingly used. In some cases, it is possible to strengthen the acetabular roof with bone cement using vertebroplasty kits. The aim of the study was to demonstrate various methods of treatment of metastatic lesions localized in the periacetabular area together with the analysis of their results and effectiveness.

METHODS

Between 2010 and 2015, 27 patients with cancer metastases to the acetabulum were treated at our department. Qualification for surgical treatment was multifaceted with numerous aspects being considered. They included patients' general condition, type of neoplasm, clinical stage, and prognosis. CT and MRI scans of the pelvis were performed in each case. Before the surgery and 3 months following the surgery, visual analogue scale (VAS) pain intensity, Karnofsky functional status, and motor ability according to the Harris scale were evaluated. Bone cement (PMMA)-augmentation was performed in 21 patients, of whom nine had cement injected precutaneously and 12 at proximal femur resection alloplasty. Hemipelvectomy Type II combined with implantation of LUMiC resection prosthesis of the acetabulum were performed in six cases.

RESULTS

The quality of life improved in all the patients. After percutaneous cement injection, the mean pain intensity VAS score was 2.7, and the mean Karnofsky functional status score was 71.8. The mean postoperative Harris hip score (HHS) was 94 points. The patients who had undergone resection alloplasty on the proximal femur combined with periacetabular cement injection were walking using one crutch. In this group of patients, the mean postoperative pain intensity, functional status, and gait efficiency scores were 4.5, 65.7, and 82 points, respectively. The mean pain intensity VAS score in patients who had LUMiC prostheses implanted was 3.4. Their mean functional status score was 65 and the gait efficiency score 71 points. All the patients were able to walk on crutches.

CONCLUSIONS

Strengthening of the acetabular roof with bone cement in a specific group of patients is an adequate method of treatment which decreases pain and allows for loading the affected limb while walking. Internal hemipelvectomy combined with LUMiC prosthesis implantation makes it possible for the patients to walk using crutches and significantly reduces pain.

Oncologic and clinical outcomes in pelvic primary bone sarcomas treated with limb salvage surgery

PURPOSE

We propose to study a group of patients with primary bone sarcoma of the pelvis treated with limb salvage surgery and analyze overall survival, local recurrence rates and functional outcomes.

METHODS

A retrospective review was performed, and all patients diagnosed with pelvic primary bone sarcomas between 1990 and 2012 were analyzed. Patients treated with limb salvage surgery and with a minimum of 12-month follow-up for patients alive were included. The overall survival and the local recurrence rate were calculated for the assessment of oncological results. The associations with gender, age, histological grade, type of surgery, margins chemotherapy response and use of navigation were examined.

RESULTS

Fifty-two patients were included in the study. The mean age was 37 years (range 10-82), and mean follow-up was 44 months (range 8-189). Forty-five (86 %) tumors were histologically classified as high-grade sarcomas, four (8 %) as low-grade sarcomas and three (6 %) as dedifferentiated sarcomas. Cancer-specific overall survival was 37.5 % for 5 years and 31 % for 10 years. Local recurrence rate was 30 %. High-grade tumors and chemotherapy necrosis below 90 % were negative prognosis factor. Postoperative complication rate was 34.5 % (n:18), being deep infection the most prevalent (n:13). Reconstruction of the pelvis after an oncology resection for primary pelvic sarcomas increased the incidence of complication significantly (p < 0.001).

CONCLUSION

Primary bone sarcomas involving the pelvis are suggestive of a high-grade tumor and present poor oncologic outcomes. Pelvic reconstruction after a limb salvage surgery is associated with a high risk of complication.

LEVEL OF EVIDENCE

Case series, Level IV.

The effect of an external hip joint stabiliser on gait function after surgery for tumours located around the circumference of the pelvis: analysis of seven cases of internal hemipelvectomy or proximal femur resection

PURPOSE

Limb-sparing resection of malignant pelvic tumours provides the opportunity for patients to obtain better post-operative mobility. However, because few studies have examined in detail the gait function of patients following pelvic tumour resection, the factors affecting gait performance remain to be clarified. Here, with the laboratory-based computer-assisted gait analysis, we evaluated these patients' gait objectively and the impact of a hip-stabilising supporter on gait improvement was simultaneously examined.

METHODS

Three-dimensional gait analysis was performed to obtain cross-sectional data for seven post-operative patients (mean age, 42.7 years; range, 20-61 years) who underwent various types of resection, including P1/4 internal hemipelvectomy (IH), P1/2/3 IH, and proximal femur resection with prosthetic reconstruction. To assess the immediate effects of a hip joint stabiliser, we instructed subjects to walk at their self-selected preferred speed and compared gait parameters with and without use of the hip stabiliser.

RESULTS

At baseline, the average walking speed was 0.75 m/s (95% CI 0.53-0.97). As shown by the intra-subject comparison, the hip stabiliser increased walking speed in all but one subject, increasing both temporal and spatial parameters. Ground reaction force of operated limbs increased for some subjects, while step length increased on at least one side in all subjects.

CONCLUSIONS

Improvement in the gait parameters is indicative of better control provided by the external hip stabiliser over the affected limb. Moreover, our findings show the potential of a biomechanical approach to improve gait function following pelvic tumour resection.

Clinical Outcomes of Surgical Treatments for Primary Malignant Bone Tumors Arising in the Acetabulum

The functional and oncologic results of eighteen patients with primary malignant periacetabular tumors were reviewed to determine the impact of surgical treatment. The reconstruction procedures were endoprosthesis (11), hip transposition (4), iliofemoral arthrodesis (2), and frozen bone autograft (1). After a mean follow-up of 62 months, 13 patients were alive and 5 had died of their disease; the 5-year overall survival rate was 67.2%. The corresponding mean MSTS scores of patients with endoprosthesis (11) and other reconstructions (7) were 42% and 55% (49%, 68%, and 50%), respectively. Overall, postoperative complications including deep infection or dislocation markedly worsened the functional outcome. Iliofemoral arthrodesis provided better function than the other procedures, whereas endoprosthetic reconstruction demonstrated poor functional outcome except for patients who were reconstructed with the adequate soft tissue coverage. Avoiding postoperative complications is highly important for achieving better function, suggesting that surgical procedures with adequate soft tissue coverage or without the massive use of nonbiological materials are preferable. Appropriate selection of the reconstructive procedures for individual patients, considering the amount of remaining bone and soft tissues, would lead to better clinical outcomes.

Resection and reconstruction of pelvic bone tumors

The objective of this study was to assess outcome and recurrence rate after limb-salvage surgery with reconstruction for pelvic bone tumors and analyze complications and their relationship with surgery. The authors analyzed 129 patients followed for a mean of 6 years (range, 2-19 years). Chondrosarcoma was the most frequent histotype. Thirty-one cases with no acetabular involvement were reconstructed with allograft only. Acetabular resections were reconstructed with allograft prosthetic composite (n=60), allograft only (n=11), trabecular metal components (n=2), prosthesis only (n=10), saddle prosthesis (n=11), and iliofemoral arthrodesis (n=1). Margins were wide (n=94), wide contaminated (n=22), marginal (n=7), and intralesional (n=6). Oncologic outcomes were as follows: 75 patients were continuously disease free, 6 were disease free after treatment of relapse, 13 were alive with disease, 28 were dead of disease, and 5 were dead of other causes. Survival was 66% at 10 years. Local recurrence rate of malignant tumors was 22.1% and was not statistically influenced by margins (P=.140) or site (P=.933). Metastasis rate was 32.8%. Deep infection was observed in 30 (23.6%) cases, with no statistical difference between reconstructions with and without allograft (P=.09). Final external hemipelvectomy was performed in 16 cases. Newer techniques of reconstruction using stemmed acetabular cups or porous metal components combined with allograft are now available. Local control and satisfactory survival is achievable long term in patients with pelvic tumors, but this surgery implies a high rate of complications. Infection is a major complication, not influenced by the use of allografts. Amputation is rarely needed.

Customised osteotomy guides and endoprosthetic reconstruction for periacetabular tumours

PURPOSE

We sought to analyse clinical and oncological outcomes of patients after guided resection of periacetabular tumours and endoprosthetic reconstruction of the remaining defect.

METHODS

From 1988 to 2008, we treated 56 consecutive patients (mean age 52.5 years, 41.1 % women). Patients were followed up either until death or February 2011 (mean follow up 5.5 years, range 0.1-22.5, standard deviation ± 5.3). Kaplan-Meier analysis was used to estimate survival rates.

RESULTS

Disease-specific survival was 59.9 % at five years and 49.7 % at ten and 20 years, respectively. Wide resection margins were achieved in 38 patients, whereas 11 patients underwent marginal and seven intralesional resection. Survival was significantly better in patients with wide or marginal resection than in patients with intralesional resection (p = 0.022). Survival for patients with secondary tumours was significantly worse than for patients with primary tumours (p = 0.003). In 29 patients (51.8 %), at least one reoperation was necessary, resulting in a revision-free survival of 50.5 % at five years, 41.1 % at ten years and 30.6 % at 20 years. Implant survival was 77.0 % at five years, 68.6 % at ten years and 51.8 % at 20 years. A total of 35 patients (62.5 %) experienced one or more complications after surgery. Ten of 56 patients (17.9 %) experienced local recurrence after a mean of 8.9 months. The mean postoperative Musculoskeletal Tumor Society (MSTS) score was 18.1 (60.1 %).

CONCLUSION

The surgical approach assessed in this study simplifies the process of tumour resection and prosthesis implantation and leads to acceptable clinical and oncological outcomes.

Femur performed better than tibia in autologous transplantation during hemipelvis reconstruction

BACKGROUND

Pelvic reconstruction after hemipelvectomy can greatly improve the weight-bearing stability of the supporting skeleton and improve patients' quality of life. Although an autograft can be used to reconstruct pelvic defects, the most suitable choice of autograft, i.e., the use of either femur or tibia, has not been determined. We aimed to analyze the mechanical stresses of a pelvic ring reconstructed using femur or tibia after hemipelvectomy using finite element (FE) analysis.

METHODS

FE models of normal and reconstructed pelvis were established based on computed tomography images, and the stress distributions were analyzed under physiological loading from 0 to 500 N in both intact and restored pelvic models using femur or tibia.

RESULTS

The vertical displacement of the intact pelvis was less than that of reconstructed pelvis, but there was no significant difference between the two reconstructed models. In FE analysis, the stress distribution of the intact pelvic model was bilaterally symmetric and the maximum stresses were located at the sacroiliac joint, arcuate line, ischiatic ramus, and ischial tuberosity. The maximum stress in each part of the reconstructed pelvis greatly exceeded that of the intact model. The maximum von Mises stress of the femur was 13.9 MPa, and that of the tibia was 6.41 MPa. However, the stress distribution was different in the two types of reconstructed pelvises. The tibial reconstruction model induced concentrated stress on the tibia shaft making it more vulnerable to fracture. The maximum stress on the femur was concentrated on the connections between the femur and the screws.

CONCLUSIONS

From a biomechanical point of view, the reconstruction of hemipelvic defects with femur is a better choice.

Pelvic reconstruction with allogeneic bone graft after tumor resection

OBJECTIVES

: Pelvic reconstruction after tumor resection is challenging.

METHODS

A retrospective study had been preformed to compare the outcomes among patients who received pelvic reconstructive surgery with allogeneic bone graft after en bloc resection of pelvic tumors and patients who received en bloc resection only.

RESULTS

Patients without reconstruction had significantly lower functional scores at 3 months (10 vs. 15, P = 0.001) and 6 months after surgery (18.5 vs. 22, P = 0.0024), a shorter duration of hospitalization (16 day vs. 40 days, P < 0.001), and lower hospitalization costs (97,500 vs. 193,000 RMB, P < 0.001) than those who received pelvic reconstruction. Functional scores were similar at 12 months after surgery (21.5 vs. 23, P = 0.365) with no difference in the rate of complications between the two groups (P > 0.05).

CONCLUSIONS

: Pelvic reconstruction with allogeneic bone graft after surgical management of pelvic tumors is associated with satisfactory surgical and functional outcomes. Further clinical studies are required to explore how to select the best reconstruction method. Level of Evidence IV, Case Series.

Biological reconstruction following the resection of malignant bone tumors of the pelvis

Background. Surgical treatment of malignant pelvic bone tumors can be very challenging. The objective of this retrospective study was to evaluate the oncological as well as the clinical and functional outcome after limb salvage surgery and biological reconstruction. Methods. The files of 27 patients with malignant pelvic bone tumors, who underwent surgical resection at our department between 2000 and 2011, were retrospectively analyzed (9 Ewing's sarcoma, 8 chondrosarcoma, 4 osteosarcoma, 1 synovial sarcoma, 1 malignant fibrous histiocytoma, and 4 carcinoma metastases). Results. After internal hemipelvectomy reconstruction was performed by hip transposition (n = 16), using autologous nonvascularised fibular graft (n = 5) or autologous iliac crest bone graft (n = 2). In one patient a proximal femor prothetis and in three patients a total hip prosthesis was implanted at the time of resection. The median follow-up was 33 months. Two- and five-year disease-specific survival rates of all patients were 86.1% and 57.7%, respectively. The mean functional MSTS score was 16.5 (~55%) for all patients. Conclusion. On the basis of the oncological as well as the clinical and functional outcome, biological reconstruction after internal hemipelvectomy seems to be a reliable technique for treating patients with a malignant pelvic bone tumor.

Composite reconstruction of the hip following resection of periacetabular tumors: middle-term outcome

The records of 18 patients with periacetabular tumors who underwent composite reconstruction of the hip following resection of periacetabular tumors were analyzed retrospectively. The mean follow-up period was 49.4 months (range, 28-100 months). During follow-up, 3 patients died and one had recurrence. Fifteen patients achieved favorable walking function; 8 had normal hip function and 7 had partial recovery of flexion function of the hip. The mean MSTS rating for hip function was 76.9%. Two patients had common peroneal nerve injury which was resolved in one of them. Middle-term follow-up showed that composite reconstruction of the hip following resection of periacetabular tumors can effectively remove tumors and provide favorable hip function for these patients. This approach is simple and less costly, and can be widely used.

[Partial pelvic resection (internal hemipelvectomy) and endoprosthetic replacement in periacetabular tumors]

OBJECTIVE

Treatment of tumors of the pelvic girdle by resection of part or all of the innominate bone with preservation of the extremity. Implantation and stable fixation using a custom-made megaprosthesis to restore painless joint function and loading capacity. The surgical goal is to obtain a wide surgical margin and local tumor control.

INDICATIONS

Primary bone and soft tissue sarcomas, benign or semi-malignant aggressive lesions, metastatic disease (radiation resistance and/or good prognosis).

CONTRAINDICATIONS

Limited life expectancy and poor physical status, extensive metastatic disease, persistent deep infection or recalcitrant osteomyelitis, poor therapeutic compliance, local recurrence following a previous limb-sparing resection, extensive infiltration of the neurovascular structures and the intra- and extrapelvic soft tissues.

SURGICAL TECHNIQUE

Levels of osteotomy are defined preoperatively by a CT-controlled manufactured three-dimensional 1:1 model of the pelvis. Using these data, the custom-made prosthesis and osteotomy templates are then constructed by the manufacturer. The anterior (internal, retroperitoneal) and posterior (extrapelvic, retrogluteal) aspects of the pelvis are exposed using the utilitarian incision surgical approach. The external iliac and femoral vessels are mobilized as they cross the superior pubic ramus. The adductor muscles, the rectus femoris and sartorius muscle are released from their insertions on the pelvis and the obturator vessels and nerve are transected. If the tumor extends to the hip joint, the femur is transected at a level distal to the intertrochanteric line to ensure hip joint integrity and to prevent tumor contamination. A large myocutaneous flap with the gluteus maximus muscle is retracted posteriorly. The pelvitrochanteric and small gluteal muscles are divided near their insertion in the upper border of the femur. To release the hamstrings and the attachment of the sacrotuberous ligament, the ischial tuberosity is exposed. After osteotomy using the prefabricated templates, the pelvis is released and the specimen is removed en bloc. The custom made prosthesis can either be fixed to the remaining iliac bone or to the massa lateralis of the sacrum. The released muscles are refixated on the remaining bone or the implant.

POSTOPERATIVE MANAGEMENT

Time of mobilization and degree of weight-bearing depends on the extent of muscle resection. Usually partial loading of the operated limb with 10 kg for a period of 6-12 weeks, then increased loading with 10 kg per week. Thrombosis prophylaxis until full weight bearing. Physiotherapy and gait training. At follow-up, patients are monitored for local recurrence and metastases using history, physical examination, and radiographic studies.

RESULTS

Between 1994 and 2008, 38 consecutive patients with periacetabular tumors were treated by resection and reconstruction with a custom-made pelvic megaprosthesis. The overall survival of the patients was 58% at 5 years and 30% at 10 years. One or more operative revisions were performed in 52.6% of the patients. The rate of local recurrence was 15.8%. Deep infection (21%) was the most common reason for revision. In two of these cases (5.3%), a secondary external hemipelvectomy had to be performed. There were four cases of aseptic loosening (10.5%) in which the prosthesis had to be revised. Six patients had recurrent hip dislocation (15.8%). In four of them a modification of the inserted inlay and an implantation of a trevira tube had to be performed respectively. Peroneal palsy occurred in 6 patients (15.8%) with recovery in only two. There were 4 operative interventions because of postoperative bleeding (10.5%). The mean MSTS score for 12 of the 18 living patients was 43.7%. In particular, gait was classified as poor and almost all patients were reliant on walking aids. However, most patients showed good emotional acceptance.

Pelvic massive allograft reconstruction after bone tumour resection

PURPOSE

The purpose of this report was to retrospectively review a series treated with pelvic tumour resection and massive allograft reconstruction, and determine survival of patients and implants, functional results and morbidity of surgical technique.

METHODS

From 1999, 33 patients underwent pelvic tumour resection and massive allograft reconstruction. The mean age was 40 years (range, 14-72) and 29 patients had a primary malignant tumour. The resection involved the acetabular area in all but three patients.

RESULTS

At a median follow-up of 33 months (range, two-143) four patients had local recurrence. The morbidity was high: five deep infections (15 %), requiring two allograft removal, six hip dislocations (18 %), eight sciatic nerve palsy (24 %), persistent in six cases, and two loosening of the acetabular component. Implant survival was 87.3 % at last follow up. The cumulative overall patient's survival was 41.5 % at five and ten years. The average MSTS functional score was 70 % (range, 54-100 %) when the acetabulum was preserved while it was 61 % (30-100 %) in patients with acetabular resection.

CONCLUSION

In conclusion, pelvic allografts represent a valid option for reconstruction after resection of pelvic tumours but due to the associated morbidity, patients should be carefully selected.

Primary tumor of the periacetabular region: resection and reconstruction using a segmental ipsilateral femur autograft

INTRODUCTION

Bone reconstruction, after periacetabular tumour removal, is a complex procedure that carries a high morbidity rate and can result in poor clinical outcomes. Among the available options, the Puget pelvic resection-reconstruction procedure uses an autograft from the ipsilateral proximal femur to restore the anatomical and mechanical continuity of the pelvic ring before inserting an acetabular implant. HYPOTHESIS AND GOALS: This reconstruction technique satisfactorily restores the pelvic anatomy such that functional results and morbidity are comparable to alternative reconstruction techniques.

PATIENTS AND METHODS

This was a retrospective study of 10 patients with an average age of 38.2 years (range 19 to 75) at the surgical procedure (performed between 1986 and 2007). There were five chondrosarcomas, three Ewing tumours, one plasmacytoma and one giant cell tumour. The position of the hip centre of rotation after reconstruction and autograft integration were evaluated on radiographs. Functional results were evaluated through the Musculoskeletal Tumor Society (MSTS) score and the Postel and Merle d'Aubigné (PMA) score.

RESULTS

At the time of review, one patient was lost to follow-up and four had died. On radiographs, the hip centre of rotation after reconstruction was higher by a median value of 15 mm (range 5 to 35) and more lateral by a median value of 6mm (range -5 to 15). Upon evaluation of radiographs at a median time of 40 months (range 6 to 252 months), the autograft was completely integrated in five patients and partially integrated in three patients (two patients had a local recurrence). There were no cases of autograft fracture or non-union at the junctions of the graft. The median MSTS score was 25 out of 30 (range 20 to 29), or 83% (range 67 to 97%) at the median clinical follow-up of 82 months (range 49 to 264). The median PMA score was 13 out of 18 (range 12 to 18). All living patients were walking without assistance. Five patients required nine surgical revisions. Seven were attributed directly or indirectly to local recurrence; one revision was performed because of instability and one because of early acetabular loosening at 9 months.

CONCLUSION

This challenging procedure provides satisfactory mechanical and anatomical results, while restoring hip anatomy and function. The primary cause of failure in this series was local recurrence of the tumour, which highlights the need to carefully select the indications and optimize the surgical tumour resection.

The anatomy of proximal femoral autografts for pelvic reconstruction: a cadaveric study

PURPOSE

One important reconstruction procedure following pelvic tumor resection is ipsilateral femoral autograft reconstruction in which the autograft is transposed onto the defect and a conventional total hip replacement is implanted in the autograft. The purpose of this study is to provide anatomical evidence for this reconstruction by measurement of proximal femoral autografts.

METHODS

The anatomical study of proximal femoral autografts was performed on thirteen fresh-frozen Chinese male cadavers. Four parameters were measured and included the diameter of the femoral head (DFH), the distance from the apex of the greater trochanter perpendicular to the medial cortex edge of the femoral neck (DAM), the length between the apex of the femoral head and the midpoint of osteotomy line under the lesser trochanter (LAM), and the width of the greater trochanter from anterior to posterior (WG). The correlation between height and each of the various parameters was analyzed using the Spearman's correlation.

RESULTS

The median (first and third quartile) values of the measurements for the above mentioned parameters were 49 mm (48-52.7 mm), 58.5 mm (54.5-60.9 mm), 102 mm (96-105.2 mm) and 48 mm (46.5-51 mm), respectively. There was a positive correlation between height and each of these four parameters (P < 0.05).

CONCLUSIONS

The proximal femoral autograft reconstruction may be a good option after resection of a pelvic tumor because of the provision of biological reconstruction. However, an individual preoperative plan should be carefully performed following evaluating the size of the bone defect after tumor resection and height and width of the remaining greater trochanter prior to conventional hip replacement.

Health-related quality of life (EQ-5D) before and after orthopedic surgery

BACKGROUND AND PURPOSE

Population data on mortality and life expectancy are generally available for most countries. However, no longitudinal data based on the health-related quality of life outcome from the EQ-5D instrument have been reported for orthopedic patients. We assessed the effect of orthopedic surgery as measured by EQ-5D.

METHODS

We analyzed EQ-5D data from 2,444 patients who were operated at the Department of Orthopedic Surgery at Karolinska University Hospital, 2001-2005. We also made a comparison between results from this cohort and those from a Swedish EQ-5D population survey.

RESULTS

The mean EQ-5D (index) score improved from 0.54 to 0.72. Hip and knee arthroplasty, operations related to previous surgery, trauma-related procedures, and rheumatoid arthritis surgeries had preoperative EQ-5D (index) scores of 0.48 to 0.52. All of these groups showed substantial improvement in scores (0.63 to 0.80). Patients with tumors or diseases of the elbow/hand showed higher preoperative scores (0.66 to 0.77), which were similar postoperatively. In most patients, the EQ-5D (index) score improved but did not reach the level reported for an age- and sex-matched population sample (mean difference = 0.11).

INTERPRETATION

Our results can be used as part of the preoperative patient information to increase the level of patient awareness and cooperation, and to facilitate rehabilitation. In future it will be possible-but not easy-to use the EQ-5D instrument as a complementary consideration in clinical priority assessment.

The use of CT derived solid modelling of the pelvis in planning cancer resections

CLINICAL PROBLEM

Resection of malignant tumors of the pelvis is demanding. To avoid disabling hemipelvectomies, years ago internal hemipelvectomy combined with partial pelvic replacements had become a surgical procedure. To achieve adequate reconstructions custom-made replacements were recommended. In early stages of the surgical procedure using megaprostheses, individual pelvic models were manufactured.

AIM OF THE STUDY

Since little is known about the accuracy of such models we analysed the charts of 24 patients (25 models) for whom an individual model of the osseous pelvis had been manufactured.

RESULTS

Two patients refused surgery. In 23 patients partial resection of the bony pelvis was performed followed by a partial pelvic replacement (13x), hip transposition procedure (5x), ilio-sacral resection (4x), or revision surgery. In all patients who received a partial pelvic replacement, the fit of the replacement was optimal. No major unplanned resection was necessary. The same was observed in patients who received a hip transposition procedure or an ilio-sacral resection. Oncologically, in most of the patients we achieved wide resection margins (14x). In 5 patients the margins were marginal (4x) or intralesional (1x). In two cases the aim was a palliative resection because of a metastatic disease (1x) or benign entity (1x).

CONCLUSION

Pelvic models are helpful tools to planning the manufacture of partial pelvic replacements and ensuring optimal osseous resection of the involved bone. Further attempts have to be made to evaluate the aim of navigational techniques regarding the accuracy of the osseous and soft-tissue resection.

The Friedman-Eilber resection arthroplasty of the pelvis

It has been argued that internal hemipelvectomy without reconstruction of the pelvic ring leads to poor ambulation and inferior patient acceptance. To determine the accuracy of this contention, we posed the following questions: First, how effectively does a typical patient ambulate following this procedure? Second, what is the typical functional capacity of a patient following internal hemipelvectomy? In the spring of 2006, we obtained video documentation of eight patients who had undergone resection arthroplasty of the hemipelvis seen in our clinic during routine clinical followup. The minimum followup in 2006 was 1.1 years (mean, 8.2 years; range, 1.1-22.7 years); at the time of last followup in 2008 the minimum followup was 2.9 years (mean, 9.8 years; range, 2.9-24.5 years). At last followup seven of the eight patients were without pain, and were able to walk without supports. The remaining patient used narcotic medication and a cane or crutch only occasionally. The mean MSTS score at the time of most recent followup was 73.3% of normal (range 53.3-80.0%; mean raw score was 22.0; range 16-24). All eight patients ultimately returned to gainful employment. These observations demonstrate independent painless ambulation and acceptable function is possible following resection arthroplasty of the hemipelvis.

LEVEL OF EVIDENCE

Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Pelvic chondrosarcomas: surgical treatment options

INTRODUCTION

Chondrosarcoma (CS) is a primary malignant bone tumor with cartilaginous differentiation. The only available treatment is carcinological surgical resection since the usual adjuvant treatments are ineffective. The pelvic location creates specific technical difficulties both for exeresis and reconstruction. Our objective was to evaluate the carcinological and functional outcomes of inter-ilioabdominal amputation and conservative surgery.

MATERIALS AND METHODS

We retrospectively studied 59 cases of pelvis chondrosarcoma managed in our department between 1968 and 2003. Demographic, anatomopathological, surgical and survival data were analyzed. Survival was estimated by the Kaplan-Meier curves and the cumulative incidence method. Multivariate analysis was used to identify all possible independent prognostic variables.

RESULTS

There were 33 men and 26 women, with an average age of 48 years. The average follow-up duration was 94 months. Eleven patients had a grade 1 chondrosarcoma, 36 a grade 2 chondrosarcoma, five were grade 3, and seven were dedifferentiated chondrosarcoma. Eleven patients underwent an inter-ilioabdominal disarticulation, and 48 had a more conservative surgery. Resection margins proved healthy in 46 patients (78%). Eighteen patients (31%) had a local recurrence, and 12 (20%) had metastases. At last follow-up, 30 patients (51%) were still alive without any sign of recurrence. Twenty-three patients (39%) died from the disease. Multivariate analysis showed that margin invasion was associated with a definitely increased local recurrence rate. A high tumoral grade was correlated with a greater risk of metastases occurrence. These two last factors (margin status and tumor grade) as well as acetabulum involvement were correlated with a reduced survival rate. Function was better among patients treated by conservative surgery, and among them, even better when the peri-acetabular area remained intact. Our study confirmed that resection margins quality is a major prognostic factor both for local control and for survival. On the other hand, local recurrence is an adverse survival prognosis factor and is itself correlated with resection margins quality. Peri-acetabular chondrosarcoma location (in zone 2) appears to be a poor oncological prognosis factor since, in this location, obtaining healthy margins appears particularly difficult. Compared to resection, inter-ilioabdominal amputation did not prove its superiority concerning resection margins quality or survival. However, resection guaranteed a better functional outcome.

CONCLUSION

Chondrosarcoma of the pelvic girdle remains of worse prognosis than peripheral bones chondrosarcoma since the critical prognosis factor is the resection margins quality. This location, and especially the peri-acetabular zone, poses difficult specific technical problems when conservative surgery is selected. Various imaging techniques should help better envision tumor resection extent. Inter-ilioabdominal amputation should only be resorted to in non-metastatic patients, when the tumor does not seem to be removable with sufficient healthy margins guarantee, or when local conditions make it impossible to hope for a good quality reconstruction.

LEVEL OF EVIDENCE

Level IV; therapeutic retrospective study.

Aggressive treatment of non-metastatic osteosarcoma improves health-related quality of life in children and adolescents

BACKGROUND

Health-related quality of life (HRQOL) of paediatric patients with osteosarcoma has not been documented longitudinally during treatment. Aims of this prospective study were to assess treatment effects on patients' HRQOL at diagnosis, during therapy and after completion of therapy, to assess sex- and age-related differences in HRQOL ratings and to assess differences between patients' and parents' reports.

PATIENTS AND METHODS

Sixty-six patients (median age, 13.4 years) with newly diagnosed, localised disease completed three HRQOL instruments, and their parents completed two of the same instruments at diagnosis, before surgery (Week 12), at Week 23 and a median of 20 weeks after treatment completion.

RESULTS

Significant improvements in most domains and worsening of nausea were reported by patients and parents from diagnosis to Weeks 12 and 23. Symptom distress decreased from diagnosis to Weeks 12 and 23 in 81% and 64% of patients, respectively. There were no sex- and few age-related differences in scores. Scores from patients and parents achieved good agreement.

CONCLUSIONS

The HRQOL of patients improves during aggressive treatment for non-metastatic osteosarcoma, except in the domain of nausea. Clinicians can use these findings to prepare their patients for the distressing symptoms that they will likely experience at certain time points and to provide reassurance that these will significantly improve.

The primary stability of the hip transposition type IIb: a biomechanical in vitro study

BACKGROUND

The hip transposition is firmly established in pelvic sarcoma surgery. However, the primary stability of the hip transposition has not been tested yet so that the mobilisation, respectively the immobilisation of the patient so far solely relied on the experience of the surgeon. The aim of this study was to test the primary stability reliably with the help of a model and to reveal possible differences in stability between currently used anchor systems (TwinFix 6.5 and MITEK SuperAnchor).

METHODS

A biomechanical model of porcine sacra was developed to document the maximum load capacity (load to failure test) and the performance under cyclic load (100 N, 200 N, 350 N, 700 N, 1400 N, each with 1000 cycles), 28 sacra were tested in total. Macroscopic damages, displacement, yield load, stiffness and F(max) were recorded as well.

FINDINGS

The load to failure test results showed a 3.9 times higher maximum load capacity for the TwinFix 6.5 anchor (1307 N) compared to the MITEK SuperAnchor (334N). The cyclical test revealed that nearly all MITEK SuperAnchors failed at a load of 350 N. In contrast, the TwinFix 6.5 anchors resisted 4000 cycles up to a load of 1400 N.

INTERPRETATION

The TwinFix 6.5 anchor proved to be clearly superior to the MITEK SuperAnchor, resulting in the adjustment of the reconstruction technique. Therefore, the immobilisation period of a patient after a hip transposition type IIb could be shortened according to the results of the primary stability test.

Computer-assisted pelvic tumor resection: fields of application, limits, and perspectives

The treatment of malignant tumors involving the pelvic area is a challenging problem in musculoskeletal oncology due to the complex pelvic anatomy and the often large tumor size at presentation. The use of navigation systems has effectively increased surgical precision aiming at optimal preservation of pelvic structures without compromising oncologic outcome by means of improved visibility of the surgical field, and enabling intraoperative display and 3D reproduction of preoperatively determined pelvic osteotomy and resection levels. In the following sections, current developments in computer-assisted pelvic surgery are reviewed and possible fields of application, as well as limitations of navigation systems, are discussed.

Reconstruction of the pelvis after resection of malignant bone tumours in children and adolescents

The predominant tumour of the pelvic region in children and adolescents is Ewing's sarcoma followed by osteosarcoma. Both tumours are treated by chemotherapy and the best chance of survival is offered by wide tumour resection. Compared to surgical treatment on the extremities, the resection and reconstruction of pelvic sarcomas remains challenging. Surgery of pelvic sarcomas shows higher rates of local recurrence and complications and a lower functional outcome than other localisations. Especially in children and adolescents the reconstruction methods have to focus additionally on the growing skeleton. According to the different types of pelvic resections and therefore the need of different reconstruction methods, the following article is based on Enneking's surgical classification of pelvic resections. Type I resections are best reconstructed with autografts implanted between the supracetabular osteotomy and the sacrum. Patients show the best functional results after this reconstruction. Periacetabular resections (type II) in small children do best with iliofemoral arthrodesis or pseudarthrosis; in larger adolescents the use of the pedestal Schoellner cup showed superior results over the prior saddle prosthesis. Type III resections are not reconstructed. Complete internal hemipelvectomy represents the most difficult situation, in children as well as in adults. High complication rates after allograft and endoprosthetic reconstruction have recently favoured the renaissance of a flail hip reconstruction or the hip transpositionplasty.